Certificate of Medical Necessity
Form for manual wheelchair
Section 1A – Patient Information
Date of Birth
Section 1B – Supplier Information
Section 1C – Physician Information
Section 2 – Medical Necessity Information
Note: Physician, if this section is blank, please complete.
Is the patient’s condition such that without the
use of a wheelchair, he/she would otherwise
Initial Certification Date
Revised Certification Date
be bed or chair confined?
Is the patient able to ambulate with crutches
Estimated length of need (number of months)
1 – 99 (99 = Lifetime)
Does the patient have quadriplegia, a fixed
Diagnosis codes (ICD-10) – separate with a comma:
hip angle, a trunk cast or brace, excessive
extensor tone of the trunk muscles or a need
to rest in a recumbent position two or more
times during the day?
Does the patient have a cast, brace or
musculoskeletal condition which prevents
90-degree flexion of the knee, or does the
What percent of the day does the patient usually spend
patient have significant edema of the lower
in the wheelchair?
extremities that requires an elevating leg-rest
or is reclining back ordered?
Does the patient have a need for arm
height different than those available using
Please continue on the next page.
An independent licensee of the Blue Cross Blue Shield Association.